Open-Heart Correction of Mitral Valvular Disease: Review of 30 Cases

Thirty patients with mitral valve disease operated upon by the open-heart technique during the period 1958-1962 were studied. In 15 insufficiency predominated. Clinical, radiological and pathological findings included the following: aortic valve disease is the commonest associated lesion; cusp calcification is uncommon in mitral insufficiency; left atrial enlargement is more pronounced in mitral insufficiency; a relaxed annulus is the commonest pathological lesion associated with mitral insufficiency, with ruptured chordae in second place. Five of the 15 patients with mitral insufficiency and four of the 15 with mitral stenosis died during the postoperative period, while clinical improvement was apparent in seven and 11, in the respective groups. The standard techniques of annuloplasty, suturing of ruptured chordae, and open commissurotomy were found to provide satisfactory results. Partial Ivalon prosthetic replacement was unsatisfactory. The study suggests that a more liberal use of the open-heart procedure in surgical correction of complicated mitral valve lesions is indicated.     

冠心病合并缺血性二尖瓣关闭不全的手术方案探讨

目的:探讨适用于冠心病合并缺血性二尖瓣关闭不全的手术方法及临床效果,为心外科手术提供参考。方法:选取2012年2月至2013年5月在我院心脏外科接受手术治疗的冠心病合并缺血性二尖瓣关闭不全的患者31例。根据手术方式的不同,将所选病例分为二尖瓣成形术组和二尖瓣置换术组。术后随访6-24个月,观察并比较患者手术前后的左心房内径(LAD)、舒张末期直径(LVEDD)、收缩末期直径(LVESD)、左心室射血分数(LVEF)及二尖瓣返流面积。结果:围术期死亡1例,手术成功率为96.7%。30例成功获得随访,随访率为98.8%。二尖瓣成形术组并发症的发生率为22.7%,二尖瓣置换术组并发症的发生率为23.3%,两组术后并发症的发生率无显著差异(P0.05)。与手术前相比,两组患者术后的左心房内径变小,左室舒张末直径和收缩末直径增加,左室射血分数升高,二尖瓣反流面积缩少,差异显著且具有统计学意义(P0.05)。结论:对于冠心病合并重度缺血性二尖瓣关闭不全的患者行二尖瓣成形术或置换术应根据患者的实际情况和病理特点选择最佳的手术方案,以提高手术的成功率和安全性。     

Recommended Criteria for Cardiac Catheterization in Patients with Aortic Valve Disease

Criteria for selection of patients with aortic valve disease for cardiac catheterization are described, based on a study of 81 cases. Children with aortic stenosis warrant catheterization at the time when the clinical diagnosis is made, but in adults this examination may be deferred until symptoms appear or left ventricular hypertrophy is recognized. In patients with pure aortic insufficiency catheterization may be deferred until symptoms appear. When severe stenosis and insufficiency co-exist, the valve is usually heavily calcified. Thirty-seven per cent of patients with aortic valve disease have co-existing mitral lesions and these patients are usually women, are fibrillating and, as a rule, have atrial enlargement in contrast to those with aortic valve disease only. On rare occasions, patients with mitral valve disease have clinically silent but angiographically demonstrable aortic insufficiency; therefore, aortography should precede open-heart correction of a mitral lesion so as to detect minor degrees of aortic insufficiency.     

AORTIC STENOSIS—Surgical Treatment Under Direct Vision,Using the Heart-Lung Machine

Cardiac operation with the operative field under direct vision and the patient''s oxygenation maintained by a heart-lung machine affords an excellent means of treating aortic stenosis, for it allows unlimited time in which to repair aortic stenosis no matter how involved the cusps are with calcium. The valves can be sculptured and the commissures cut at their place of fusion. Concomitant aortic insufficiency can also be taken care of at the same time, as can associated mitral valve stenosis and insufficiency.This method was used in ten patients. Two died. Eight were considerably improved.     

Is mitral valve repair safe procedure in elderly patients?

The aim of this randomized, prospective, study was to evaluate postoperative hospital mortality and morbidity after mitral valve repair by comparing two surgical techniques for resolving mitral valve insufficiency in elderly patients. In comparison were: mitral valve repair vs. mitral valve replacement in patients older than 70 years. In period from January 1st 2006 until August 30th 2009. Eighty patients with mitral valve disease, isolated or associated with other comorbidities, were scheduled for mitral valve repair or mitral valve replacement in our institution. Patients were randomized in two groups, one scheduled for mitral valve repair and another one for mitral valve replacement using the envelope method with random numbers. Results show no difference in hospital mortality and morbidity postoperatively in both groups. In group undergoing valve replacement we had one significant complication of ventricle rupture in emphatically calcified posterior part of mitral valve annulus. In conclusion we found no distinction in postoperative hospital mortality and morbidity after using one of two surgical techniques.     

肥厚梗阻性心肌病的外科治疗

目的:总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法:2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均(42.7±13.6)岁;左室流出道压差(LVOTGP)70～120 mmHg(1 mmHg=0.133Kpa),平均(95.0±22.6)mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术(MVR)7例,二尖瓣成形术(MVP)7例,二尖瓣、主动脉瓣成形术(MVP+AVP)5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术(MVP+AVP+CABG)2例。分析比较病人术前超声心动图(UCG),术中经食管心脏超声(TEE),以及术后1周、3月、6月、1年超声心动图结果。结果:手术死亡1例(3.0%,1/33例),主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例(3.0%,1/33例)。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象(SAM征)消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论:外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。     

A case of colonization of a prosthetic mitral valve by Acremonium strictum

A case of colonization of a prosthetic mitral valve in a 73-year-old Spanish male by the fungus Acremonium strictum W. Gams is described. The valve was replaced due to paravalvular leak and severe insufficiency and the patient died of multiorgan failure. The identity of the fungus was determined by morphological studies and it was confirmed by the analysis of the ITS region sequence analysis. Molecular studies seem to demonstrate that A. strictum is a species complex. The case emphasizes the potential high risk of fungal infection for patients with prosthetic valves.     

肥厚梗阻性心肌病的外科治疗

目的：总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法：2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均（42.7±13.6）岁;左室流出道压差（LVOTGP）70～120 mmHg（1 mmHg=0.133Kpa）,平均（95.0±22.6）mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术（MVR）7例,二尖瓣成形术（MVP）7例,二尖瓣、主动脉瓣成形术（MVP＋AVP）5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术（MVP＋AVP＋CABG）2例。分析比较病人术前超声心动图（UCG）,术中经食管心脏超声（TEE）,以及术后1周、3月、6月、1年超声心动图结果。结果：手术死亡1例（3.0%,1/33例）,主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例（3.0%,1/33例）。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象（SAM征）消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论：外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。     

DIASTOLIC OPENING OF THE AORTIC VALVE (AV) IN A CASE OF AORTIC INSUFFICIENCY DUE TO AV FENESTRATION

A patient with severe aortic insufficiency due to fenestration of the non-coronary aortic valve leaflet is described. A preoperative echocardiogram demonstrated early closure of the mitral valve and early diastolic separation of the aortic valve leaflets. These findings disappeared after partial surgical correction and subsequent hemodynamic improvement. Premature opening of the aortic valve is common in severe aortic insufficiency.     

Mitral Valve Replacement in a 14-Month-Old Child

In a 14-month-old child with severe congenital mitral insufficiency, the mitral valve was replaced with a Starr-Edwards valve. This resulted in dramatic improvement and the child continues to thrive one year after surgery. The authors conclude that valve replacement should be considered in a child of any age if other methods of valve repair cannot be relied upon to produce a good result.     

Lambl's excrescences of the mitral valve

A young male patient, just recovered from a recent transient ischaemic attack, was operated on for mitral valve insufficiency due to suspected endocarditis. Multiple wear-and-tear lesions were found at the line of closure of the mitral valve, which appeared to be Lambl''s excrescences. The valve was replaced.     

Surgical Treatment of Mitral Insufficiency

Sixty-four patients with pure mitral insufficiency were operated upon. Thirty of them had torn chordae tendineae. It was possible to repair the mitral valve in 57 patients and there were five operative deaths. One patient had a femoral artery embolus and another had a cerebral embolus. The incidence of peripheral embolization was 4 per cent compared with 40 per cent reported for ball valve replacement.Forty-eight of the 57 patients with repair (84 per cent) were living and well with at most a grade II/VI apical systolic murmur up to seven and a half years after operation. There has been no evidence of recurrence in these patients.In approximately 90 per cent of patients with pure mitral insufficiency, repair should be performed. When feasible, repair is more satisfactory than valvular replacement, with not only excellent long-term results, but far less morbidity than is reported with ball valve replacement.     

Replacement of the Aortic and Mitral Valves Using the Starr-Edwards Ball-Valve Prosthesis: A Report of 50 Cases

The aortic and mitral valves were replaced in 50 patients at the University of Alberta Hospital using the Starr-Edwards ball-valve prosthesis. The basis of the selection of 20 patients for isolated aortic valve replacement and 27 for mitral valve replacement using this type of prosthesis is presented, and the techniques of insertion of the aortic and mitral valve are described in detail. Of the 27 patients in whom the mitral valve was replaced by the Starr-Edwards prosthesis six died within 30 days of surgery and two after discharge from hospital at two and a half and four months, respectively. Left atrial thrombosis was the cause of death in four of these patients. In 20 patients in whom the aortic valve was replaced, four died in hospital and two died more than 30 days after returning home. Three of these six patients died from bleeding—the result of the use of anticoagulants. The difficulty in assessing whether or not anticoagulants are needed following replacement by a Starr-Edwards prosthesis is considered. It is felt, in our present state of knowledge, that anticoagulants should be used following mitral valve replacement but are probably not essential following replacement of the aortic valve. Two patients survived replacement of both aortic and mitral valves and have been followed up 18 months and seven months, respectively.     

Heart valve replacement in the elderly.

From January 1973 to December 1976, 70 operations for heart valve replacement were performed on 68 patients aged 65--75 years. These comprised 40 aortic valve replacements, 27 mitral valve replacements, and three aortic and mitral valve replacements. Three patients died within 30 days of operation (early mortality 4.3%), and five died 12 weeks to three years after operation. Four patients showed no improvement. The results were excellent or good in the remaining 56 patients. Valve replacemnt can restore to a useful independent life elderly patients who would otherwise be a burden on costly social and medical domiciliary services. The indications for valve surgery in the elderly should therefore be the same as in any other age group.     

Factitious Aortic Valve Insufficiency

One hundred consecutive aortograms, performed with careful attention to recommended technical details, were reviewed to identify cases of “factitious” aortic valve insufficiency, viz. aortic regurgitation seen during aortography for which there is no clinical evidence. Five patients with this condition were identified. Two of these subsequently underwent mitral valve replacement under cardiopulmonary by-pass. Aortic insufficiency was not detected during this procedure and the aortic valve appeared to be anatomically normal at postmortem examination. That factitious aortic insufficiency may exist should be remembered when aortography is used to differentiate aortic from pulmonary valve insufficiency.     

A SECOND CASE OF LATE EMBOLIZATION OF PROSTHETIC MITRAL VALVE OCCLUDER WITH SURVIVAL FOLLOWING REOPERATION

A 51-year-old male with acute fulminating pulmonary edema and cardiogenic shock secondary to severe mitral insufficiency from dislodgment of the disc occluder in a Wada-Cutter valve was treated by immediate open heart procedure with a Bjork-Shiley mitral valve replacement. The patient survived and remains well. This is the second patient reported to survive operation and replacement of a malfunctioning prosthetic mitral valve from which the poppet escaped and embolized. The first case was reported by Hughes et al(1) in February, 1975. Some striking similarities, as well as differences, in these two cases are discussed.     

Left heart catheterization; the clinical importance of findings

Left heart catheterization using the transbronchial route to obtain pressures in the left atrium and left ventricle was used successfully in 29 cases with no mortality or morbidity. It was found to be useful in differentiating between mitral stenosis and mitral insufficiency, as well as determining the amount of aortic stenosis present when there was involvement of the aortic valve. The technique was also helpful in determining which is the predominant lesion when there is a disease of the aortic and mitral valves. In two patients in a series of 29, data obtained by left heart catheterization forestalled operation on the basis of a mistaken diagnosis of mitral stenosis when actually no mitral valvular disease was present. In another eight patients, the predominant lesion was found to be mitral stenosis rather than mitral insufficiency as it was thought to be before catheterization. In two patients, who had only systolic murmurs, catheterization revealed mitral stenosis rather than mitral insufficiency. In four patients who were thought to have mixed valvular disease, left heart catheterization showed only aortic valvular disease.     

Sudden,Severe Mitral Insufficiency

Five male patients with sudden, severe mitral insufficiency due solely to ruptured chordae tendineae or papillary muscle had an abrupt onset of symptoms of left and right heart failure and the sudden appearance of a harsh, widely propagated apical pansystolic murmur. None had a history of rheumatic fever. All were in sinus rhythm and had but mild left atrial and ventricular enlargement. Giant left atrial “v” waves were characteristic and exceeded pulmonary artery pressure in two instances.In contrast, when ruptured chordae tendineae were superimposed on chronic rheumatic mitral insufficiency, females predominated and there was a long history of disability. Atrial fibrillation, less elevation of left atrial pressure, and marked left atrial and ventricular enlargement were characteristic. These latter patients closely resembled patients with chronic rheumatic mitral insufficiency alone.It is concluded that the syndrome of sudden, severe mitral insufficiency develops if ruptured chordae tendineae occur on a previously normal or insignificantly diseased mitral valve. If ruptured chordae tendineae are superimposed on chronic rheumatic mitral insufficiency, the syndrome resembles that seen in the latter alone.     

LEFT HEART CATHETERIZATION—The Clinical Importance of Findings

Left heart catheterization using the transbronchial route to obtain pressures in the left atrium and left ventricle was used successfully in 29 cases with no mortality or morbidity. It was found to be useful in differentiating between mitral stenosis and mitral insufficiency, as well as determining the amount of aortic stenosis present when there was involvement of the aortic valve. The technique was also helpful in determining which is the predominant lesion when there is a disease of the aortic and mitral valves.In two patients in a series of 29, data obtained by left heart catheterization forestalled operation on the basis of a mistaken diagnosis of mitral stenosis when actually no mitral valvular disease was present. In another eight patients, the predominant lesion was found to be mitral stenosis rather than mitral insufficiency as it was thought to be before catheterization. In two patients, who had only systolic murmurs, catheterization revealed mitral stenosis rather than mitral insufficiency. In four patients who were thought to have mixed valvular disease, left heart catheterization showed only aortic valvular disease.     

Physiology of the mitral valve of adult humans during exercise

Voluntary cessation of external respiration combined with additional physical work during 17–33 s was accompanied by an increase in energy expenditure to 0.05 kcal/(kg min) and an increase in the heart rate and stroke volume. The blood flow through the mitral valve was accelerated from 0.95 to 1.14 m/s during the free left ventricular filling phase. The total cardiac cycle duration shortening from 0.86 to 0.68 s, the time during which the mitral valve remained open was 0.30 s.